Sentinel node biopsy in head and neck squamous cell carcinoma

Improving Survival of T3cN0M0 Glottic Squamous Cell Cancer With Elective Neck Dissection

OBJECTIVES/HYPOTHESIS

This study aimed to elucidate the role of elective neck dissection (END) in improving the outcome of T3cN0M0 glottic squamous cell cancer (GSCC).

STUDY DESIGN

Retrospective population-based database analysis.

METHODS

Patients with T3cN0M0 GSCC in the Surveillance, Epidemiology, and End Results database (SEER) were extracted and stratified into END and non-END cohorts. Propensity score matching (PSM) was used to eliminate the baseline variations. The Kaplan-Meier method was performed to access the association between END and survival.

RESULTS

We retrospectively analyzed 1,589 T3cN0M0 GSCC patients in the SEER database from 2004 to 2015, and found that only 22% to 58% T3cN0M0 GSCC were performed with END. After PSM, END cohort had better overall survival (OS) (median survival time: 93 vs. 55 months, respectively; P = .0047) and cancer-specific survival (CSS) (hazard ratio [HR] 0.48, 95% confidence interval [CI] 0.29-0.77, P = .003) than non-END cohort. In addition, Subgroup analysis also indicated END cohort had better OS or CSS than non-END cohort.

CONCLUSION

This study demonstrated that in patients with T3cN0M0 GSCC, END significantly associated with better survival outcomes compared with non-END.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Paradoxical Roles of Desmosomal Components in Head and Neck Cancer

Desmosomes are intercellular adhesion complexes involved in various aspects of epithelial pathophysiology, including tissue homeostasis, morphogenesis, and disease development. Recent studies have reported that the abnormal expression of various desmosomal components correlates with tumor progression and poor survival. In addition, desmosomes have been shown to act as a signaling platform to regulate the proliferation, invasion, migration, morphogenesis, and apoptosis of cancer cells. The occurrence and progression of head and neck cancer (HNC) is accompanied by abnormal expression of desmosomal components and loss of desmosome structure. However, the role of desmosomal components in the progression of HNC remains controversial. This review aims to provide an overview of recent developments showing the paradoxical roles of desmosomal components in tumor suppression and promotion. It offers valuable insights for HNC diagnosis and therapeutics development.

How is neck dissection performed in Oral and Maxillofacial Surgery? Results of a representative nationwide survey among university and non-university hospitals in Germany

Introduction

Neck dissection (ND) is a surgical procedure addressing cervical lymph nodes and metastases in patients with oral squamous cell carcinoma (OSCC). The aim of this study was to analyze clinical decisions regarding indications and variations of ND in Oral and Maxillofacial Surgery (OMFS) in Germany.

Material and methods

A nationwide survey of the German Association of Oral and Maxillofacial Surgery was performed using dynamic online questionnaires including 38 questions. Data about oncological centers, case numbers, and staging procedures were collected. Relevant aspects, such as inclusion of level IIb and levels IV and V to ND, uni- vs. bilateral ND, and the influence of extra-nodal extension (ENE) of metastases on extension of ND were evaluated.

Results

Eighty-four OMFS of university and non-university hospitals participated in the study (responding rate 21.4%). Sixty-six (78.57%) stated to work at certified cancer centers and 53.57% of the hospitals treated between 50 and 100 OSCC cases per year. CT and/or MRI of the head and neck was performed in most of the staging procedures. Level IIb was included by 71 (93.42%) of the participants in selective ND. Levels IV and V were included by 53 (69.74%) in node-positive neck. In solitary ipsilateral metastases (ENE−), 49 participants (62.82%) stated to perform exclusively an ipsilateral ND and 40 (51.95%) stated to perform only an ipsilateral ND in ENE+.

Conclusion

This study demonstrated a high rate of certified cancer centers in Germany showing differences regarding staging procedures, indications, and extension of ND, especially in increasingly complex cases.

Clinical relevance

Clinical decisions regarding ND are dependent on case-individual aspects and must be decided individually.

Detecting cancer metastasis and accompanying protein biomarkers at single cell levels using a 3D-printed microfluidic immunoarray

A low-cost microfluidic microarray capable of lysing cells and quantifying proteins released after lysis was designed and 3D-printed. The array lyses cells on-chip in lysis buffer augmented with a 2s pulse of a sonic cell disruptor. Detection of desmoglein 3 (DSG3), a metastatic biomarker for head and neck squamous cell carcinoma (HNSCC), along with two accompanying HNSCC biomarkers from a single cell lysate of oral cancer cell cultures was demonstrated. A lysis chamber and reagent compartments deliver sample and reagents into detection chambers decorated with capture antibodies immobilized onto inner walls coated with a highly swollen 3D chitosan hydrogel film. Sandwich immunoassays are achieved when captured analytes labeled with biotinylated secondary antibodies, which then capture streptavidin-poly [horse radish peroxidase] (Poly-HRP). Subsequent delivery of super-bright femto-luminol with H2O2 generates chemiluminescence captured with a CCD camera. DSG3 is membrane-bound protein in HNSCC cells of invaded lymph nodes, vascular endothelial growth factor-A (VEGF-A), vascular endothelial growth factor-C (VEGF-C) were positive controls overexpressed into the HNSCC culture medium. Beta-tubulin (β-Tub) was used as a loading control to estimate the number of cells in analyzed samples. Limits of detection (LOD) were 0.10 fg/mL for DSG3, and 0.20 fg/mL for VEGF-A, VEGF-C and β-Tub. Three orders of magnitude semilogarithmic dynamic ranges were achieved. VEGF-A showed high in-cell expression, but VEGF-C had low levels inside cells. The very low LODs enabled quantifying these proteins released from single cells. Strong correlation between results from on-chip cell lysis, conventional off-line lysis and ELISA confirmed accuracy.

The impact of sentinel lymph node biopsy on the quality of life in patients with oral cavity squamous cell carcinoma

INTRODUCTION

Sentinel lymph node biopsy is a proven method for staging the neck in patients with early oral cavity squamous cell carcinoma because it results in less comorbidity than the traditional method of selective neck dissection, with the same oncological results. However, the real effect of that method on the quality of life of such patients remains unknown.

OBJECTIVE

The present study aimed to evaluate the quality of life of patients with oral cavity squamous cell carcinoma T1/T2N0 submitted to sentinel lymph node biopsy compared to those that received selective neck dissection.

METHODS

Cross-sectional study including 24 patients, after a 36 month follow-up, 15 of them submitted to the sentinel lymph node biopsy and 9 to selective neck dissection. All patients answered the University of Washington quality of life questionnaire.

RESULTS

The evaluation of the questionnaires showed a late worsening of the domains appearance (p=0.035) and chewing (p=0.041), as well as a decrease of about 10% of general quality of life (p=0.025) in patients undergoing selective neck dissection ​​in comparison to those undergoing sentinel lymph node biopsy.

CONCLUSION

Patients with early-stage oral cavity squamous cell carcinoma undergoing sentinel lymph node biopsy presented better late results of general quality of life, mainly regarding appearance and chewing, when compared to patients submitted to selective neck dissection.

MR evaluation of tongue carcinoma in the assessment of depth of invasion with histopathological correlation: A single center experience

Introduction

Magnetic resonance imaging (MRI) has become the cornerstone for pretreatment evaluation of carcinoma tongue and provides accurate information regarding the extent of the lesion and depth of invasion that helps the clinician to optimize treatment strategy. Aim of the study is to correlate MRI and histopathological findings, to evaluate the role of MRI in loco-regional tumor node metastasis (TNM) staging, and to assess the depth of invasion of tongue carcinoma.

Materials and Methods

This study was undertaken on 30 patients with clinical diagnosis of tongue carcinoma referred for MR imaging at a tertiary care hospital over the 2-year period between July 2017 and June 2019. MRI was performed with GE 1.5 Tesla scanner, neurovascular (NV) array coil. Clinical and MRI staging of tongue carcinoma was done preoperatively and correlated. Post-surgery, histopathological TNM staging was done and correlated with clinical and MRI TNM staging. The cutoff value of histopathological (HP) depth that could determine the existence of nodal metastasis was 5 mm.

Results

In 30 patients diagnosed with tongue carcinoma, the incidence was higher in males (92%). Moderate agreement (k = 0.512) was noted for T staging between clinical and MRI staging assessments. Fair agreement (k = 0.218) was noted for N stage between clinical and MRI staging assessments. There was good agreement (k = 0.871) for M stage between the clinical and MRI staging assessments. Good agreement (k = 0.822 and k = 0.767, respectively) was noted for both T staging and Nstaging between MRI and histopathology staging assessments. The agreement for the T stage was poor (k = 0.012) between the clinical and histopathology staging assessments. Agreement for the N stage was also poor (k = 0.091) between the clinical and histopathology staging assessments. Mean depth of invasion by histology and MRI was 14.22 mm and 16.12 mm, respectively. Moderate agreement (k = 0.541) was noted between clinical and pathological tumor depth and good agreement (k = 0.844) was noted between radiological and pathological tumor depth. As for the T1WGd MRI depth with a cutoff value of 5 mm, the nodal metastasis rate in the group with values >5 mm was 52%, and for those <5 mm was 24%, both of which were significantly different (P = 0.040). Pearson's correlation coefficient of HP depth and T1WGd MRI depth was 0.851 (P < 0.001) suggesting that HP depth shows a strong correlation with T1WGd MRI depth.

Conclusion

MRI is the imaging modality of choice for evaluation of tongue carcinoma as MRI helps in accurate staging of the tumor using TNM classification which is crucial for optimizing treatment options. The current study shows a high correlation between MRI and histopathological findings regarding thickness of tumor and depth of invasion. MRI and histopathology assessments of tumor spread were equivalent to within 0.5 mm DOI. Estimation of invasion depth using MRI as a preoperative study in oral tongue carcinoma is essential in planning surgical treatment strategies such as the extent of elective neck dissection. Invasion depth, which greatly affects occult node metastases, must be included in the TNM staging of oral tongue carcinoma.

Lymphoscintigraphy for Sentinel Node Mapping in Head and Neck Cancer

The aim of this comprehensive review is to describe and analyze the role of the sentinel node mapping in head and neck cancers. For this purpose, head and neck neoplasms have been categorized in cutaneous malignancies and neoplasms of the upper aerodigestive tract. A concise description of lymphatic drainage will be the "prelude" for each section, as well as the description of the injection techniques, when specific. Concisely, the attention has been focused on detection rate of the sentinel node by lymphoscintigraphy for each cancer, and for those patients in which the sentinel lymph node has been identified, true-positives rates, false-negative rates, and overall accuracy has been pointed out. Overall, in cutaneous neoplasms of the head and neck, the detection rate is higher than 90%, however the false-negative rate is still an issue, in particular in melanoma, inducing the need for newer developments. In fact, new tracers and techniques are already available, while prospective multicenter trials exploring the outcome impact are needed in the near future. For the upper aerodigestive tract and in particular oral cavity and oropharynx, sentinel lymph node identification by lymphoscintigraphy allows avoiding unnecessary neck dissection and/or node irradiation. Even in this case, the main limit remains the risk of false-negative rates. While, for patients affected by laryngeal and hypopharyngeal cancers the data seem very limited and, although the feasibility has been demonstrated, performances of this lymphoscintigraphy still need to be confirmed by multicenter studies.

Detection of Occult Metastases in Patients with T1 and T2 Stage Lower Lip Squamous Cell Carcinomas after Positive Lymphoscintigraphy

The aim of this study was to detect lower lip squamous cell carcinomas (SCC) that had metastasized to the lymph nodes and to evaluate if neck dissection was necessary for patients with T1 or T2-stage lip cancer after a sentinel lymph node biopsy (SLNB). The study was conducted as a prospective clinical study to detect occult neck metastases in patients with T1 or T2 stage SCC of the lower lip. Thirty-one patients were eligible and underwent echo-ultrasound, computer tomography, magnetic resonance and lymphoscintigraphy (LSG) as diagnostic procedures. LSG was performed on the same day as the surgical procedure, after intradermal injection of 37 Mbq Tc99m-Sn-colloid/mL at four peritumoral sites. In patients with positive LSG results, the sentinel lymph nodes were extracted surgically. The risk factors for cancer development were sun exposure and smoking. The highest accuracy for detecting lymph node enlargements was achieved with magnetic resonance imaging (MRI; 80.7%). LSG showed excellent sensitivity (100%) and negative predictive value (NPV; 100%). Overall, occult metastases were diagnosed with an SLNB in eight (25.8%) patients. According to the results, with great caution, we suggest that an SLNB is reasonable to initiate only for patients with positive sentinel nodes by positive LSG, to be used as a lower morbidity approach for selected patients with T1 and T2 stage cancers.

Current thinking in management of the neck (including contralateral neck) in ipsilateral recurrent or second primary oral squamous cell carcinoma

Metastasis to the neck in patients with oral squamous cell carcinoma (SCC) has a huge impact on long-term survival and prognosis, and its incidence varies. Due consideration therefore should be given to management of the neck in each individual case. The pathways in patients with primary oral SCC are well-established, but there is a paucity of published papers on management of the neck in those with ipsilateral recurrent or second primary oral SCC whose necks have previously been operated on with or without radiotherapy or chemoradiotherapy, or treated with radiotherapy or chemoradiotherapy alone. These patients may be under treated because of failure to stage the most likely drainage site, and are likely to have a worse outcome if there is macroscopic recurrence in the neck after independent treatment of the recurrent or second primary tumour. Based on the current review, we think there is a need for a multicentre, collaborative, retrospective review of the outcomes of patients with ipsilateral second primaries or recurrent oral SCC in the previously treated neck. Our recommendations include consideration of positron emission tomography-computed tomography in all patients with recurrent or second primary oral SCC (if "hot" - neck dissection, if "cold" - sentinel node biopsy); consideration of sentinel node biopsy in all patients with recurrent or second primary oral SCC who have previously had treatment to the neck; and finally, consideration of definitive management of the sentinel biopsy zone or region if the node is invaded.

TWIST1, MMP-21, and HLAG-1 co-overexpression is associated with ESCC aggressiveness

Esophageal squamous cell carcinoma (ESCC) is one of the most aggressive types of cancer, requiring reliable biomarkers for prognosis and therapeutic responsiveness. TWIST1, as an important factor responsible for metastasis of several cancers, is involved in tumor invasion and metastasis through indirectly regulation of MMP-21 expression. On the other hand, NF-ĸβ which is a regulator of HLAG-1 has direct interaction with TWIST1 protein. In this retrospective study we investigated the clinical significance of TWIST1, MMP-21, and HLAG-1 expression in ESCC, and the possible correlation between these genes and progression of the disease. The gene expression analyses of TWIST1, MMP-21, and HLA-G1 were performed by relative comparative real-time polymerase chain reaction in 58 ESCCs compared with corresponding margin-normal esophageal tissues. Significant overexpression of HLAG-1, TWIST1, and MMP-21 messenger RNA was observed in 22.4%, 41.4%, and 60.3% of tumor samples, respectively. Concomitant overexpression of TWIST1/MMP-21 and TWIST1/HLAG-1 were significantly correlated to each other in various clinicopathological features, including depth of tumor invasion, stage of tumor progression, lymphatic invasion, and grade of tumor cell differentiation ( P < 0.05). The current study is the first report of coexpression of TWIST1, MMP-21, and HLAG-1 in ESCC. Such findings suggest an oncogenic role for concomitant expression of these genes in ESCC invasion and metastasis.

PAK2-c-Myc-PKM2 axis plays an essential role in head and neck oncogenesis via regulating Warburg effect

The histone modifiers (HMs) are crucial for chromatin dynamics and gene expression; however, their dysregulated expression has been observed in various abnormalities including cancer. In this study, we have analyzed the expression of HMs in microarray profiles of head and neck cancer (HNC), wherein a highly significant overexpression of p21-activated kinase 2 (PAK2) was identified which was further validated in HNC patients. The elevated expression of PAK2 positively correlated with enhanced cell proliferation, aerobic glycolysis and chemoresistance and was associated with the poor clinical outcome of HNC patients. Further, dissection of molecular mechanism revealed an association of PAK2 with c-Myc and c-Myc-dependent PKM2 overexpression, wherein we showed that PAK2 upregulates c-Myc expression and c-Myc thereby binds to PKM promoter and induces PKM2 expression. We observed that PAK2-c-Myc-PKM2 axis is critical for oncogenic cellular proliferation. Depletion of PAK2 disturbs the axis and leads to downregulation of c-Myc and thereby PKM2 expression, which resulted in reduced aerobic glycolysis, proliferation and chemotherapeutic resistance of HNC cells. Moreover, the c-Myc complementation rescued PAK2 depletion effects and restored aerobic glycolysis, proliferation, migration and invasion in PAK2-depleted cells. The global transcriptome analysis of PAK2-depleted HNC cells revealed the downregulation of various genes involved in active cell proliferation, which indicates that PAK2 overexpression is critical for HNC progression. Together, these results suggest that the axis of PAK2-c-Myc-PKM2 is critical for HNC progression and could be a therapeutic target to reduce the cell proliferation and acquired chemoresistance and might enhance the efficacy of standard chemotherapy which will help in better management of HNC patients.

Clinicopathological Factors of Cervical Nodal Metastasis and the Concept of Selective Lateral Neck Dissection in the Surgical Management of Carcinoma Larynx and Hypopharynx and Its Outcome

To study the clinicopathological and molecular factors which correlate with nodal metastasis in laryngeal and hypopharyngeal carcinoma, a retrospective analysis of 170 patients who underwent surgery for laryngeal and hypopharyngeal carcinoma at RCC, Trivandrum from 2006 to 2010 was done. The pathological nodal stage and levels of involvement were correlated with the clinicopathologic features of the primary disease. Neck node positivity was significantly more for lesions of pyriform sinus lesion (61%), with thyroid cartilage erosion (56%) and with base tongue involvement (88%). Other clinicopathological factors have no impact on the disease-free survival and overall survival for patients with pathologically N0 status. Elective lateral neck dissection is advisable in cases with laryngeal cartilage erosion, pyriform sinus, supraglottis and base tongue involvement.

Angiogenesis and evading immune destruction are the main related transcriptomic characteristics to the invasive process of oral tongue cancer

Metastasis of head and neck tumors is responsible for a high mortality rate. Understanding its biochemistry may allow insights into tumorigenesis. To that end we carried out RNA-Seq analyses of 5 SCC9 derived oral cancer cell lines displaying increased invasive potential. Differentially expressed genes (DEGs) were annotated based on p-values and false discovery rate (q-values). All 292 KEGG pathways related to the human genome were compared in order to pinpoint the absolute and relative contributions to the invasive process considering the 8 hallmarks of cancer plus 2 new defined categories, as well as we made with our transcriptomic data. In terms of absolute contribution, the highest correlations were associated to the categories of evading immune destruction and energy metabolism and for relative contributions, angiogenesis and evading immune destruction. DEGs were distributed into each one of all possible modes of regulation, regarding up, down and continuum expression, along the 3 stages of metastatic progression. For p-values twenty-six genes were consistently present along the tumoral progression and 4 for q-values. Among the DEGs, we found 2 novel potentially informative metastatic markers: PIGG and SLC8B1. Furthermore, interactome analysis showed that MYH14, ANGPTL4, PPARD and ENPP1 are amenable to pharmacological interventions.

MAML1 and TWIST1 co-overexpression promote invasion of head and neck squamous cell carcinoma

AIMS

Head and neck squamous cell carcinoma (HNSCC) is the seventh most common cancer worldwide with considerable morbidity and mortality. Invasion and metastasis of HNSCC is a complex process involving multiple molecules and signaling pathways. Twist Family BHLH Transcription Factor 1 (TWIST1) and Mastermind-like 1 (MAML1) are essential in induction of epithelial-mesenchymal transition through direct regulation of implicated molecules in cellular adhesion, migration and invasion. Our aim in this study was to assess the clinical significance of MAML1 and TWIST1 expression in HNSCC, and elucidate the probable correlation between these genes to exhibit their possible associations with progression and metastasis of the disease.

METHODS

The gene expression profile of MAML1 and TWIST1 was assessed in fresh tumoral compared to distant tumor-free tissues of 55 HNSCC patients using quantitative real-time Polymerase chain reaction (PCR).

RESULTS

Significant overexpression of MAML1 and TWIST1 mRNA was observed in 49.1% and 38.2% (P ˂ 0.05) of tumor specimens, respectively. Overexpression of MAML1 was associated with vascular invasion (P = 0.048). Concomitant overexpression of MAML1 and TWIST1 was significantly correlated to each other (P = 0.004). Co-overexpression of the genes was significantly correlated to the various clinicopathological indices of poor prognosis including depth of tumor invasion (P < 0.01), lymphatic invasion and grade of tumor cell differentiation (P < 0.05).

CONCLUSIONS

Significant correlation between MAML1 and TWIST1 in HNSCC was revealed. This study was the first report elucidating MAML1 clinical relevance in HNSCC. These new findings suggest an oncogenic role for concomitant expression of MAML1 and TWIST1 genes in HNSCC invasion and metastasis.

Comparison of SPECT/CT and Planar Lympho-scintigraphy in Sentinel Node Biopsies of Oral Cavity Squamous Cell Carcinomas

Introduction:

Evidence supporting the use of Sentinel node biopsy (SNB) for nodal staging of early oral squamous cell carcinomas (OSCC) appears to be very promising. Pre-operative lymphatic mapping using planar lymphoscinitigraphy (PL) with or without SPECT/CT in the SNB procedure is useful in sentinel node localization and for planning appropriate surgery. Recently, a large prospective multi-centric study evaluating SNB in cutaneous melanoma, breast and pelvic malignancies, demonstrated that adding SPECT to PL leads to surgical adjustments in a considerable number of patients. Our aim of this study was to evaluate the incremental value of additional SPECT/CT over PL alone in SNB for OSCC.

Materials and Methods:

This was a retrospective analysis of 44 patients (40- tongue, 4- buccal mucosa) with T1-T2, clinically N0 oral cavity SCC who underwent sentinel node biopsy procedure. PL and SPECT lymphoscinitigraphy images were compared for pre-operative mapping of sentinel nodes.

Results:

Using a handheld gamma probe, a total of 179 sentinel nodes were harvested, with a mean of 4.06 per patient. PL revealed 75 hotspots with a mean of 1.70 per patient, and SPECT/CT revealed 92 hotspots with a mean of 2.09 per patient. Additional hotpots were identified in 14 patients on SPECT/CT, which included 4 patients, where PL did not detect any sentinel nodes.

Conclusion:

Pre-operative SPECT/CT in addition to planar lympho-scinitigraphy in sentinel node biopsies of oral cavity SCC detects more number of sentinel nodes compared to planar imaging alone. The higher sensitivity of SPECT combined with better anatomical localization using diagnostic CT may further improve the precision of SNB procedure.

Correlation between clinical and MRI assessment of depth of invasion in oral tongue squamous cell carcinoma

Background

Neck metastasis is the most important prognostic factor in oral cavity squamous cell carcinomas (SCC). Apart from the T- stage, depth of invasion has been used as a highly predictable factor for microscopic neck metastasis, despite the controversy on the exact depth cut off point. Depth of invasion can be determined clinically and radio logically. However, there is no standard tool to determine depth of invasion preoperatively. Although MRI is used widely to stage the head and neck disease, its utility in depth evaluation has not formally been assessed.

Objective

To compare preoperative clinical and radiological depth evaluation in oral tongue SCC using the standard pathological depth.

To compare clinical and radiological accuracy between superficial (<5 mm) vs. deep invaded tumor (≥5 mm)

Methods

This prospective study used consecutive biopsy-proven oral tongue invasive SCC that presented to the University health network (UHN), Toronto. Clinical examination, radiological scan and appropriate staging were determined preoperatively. Standard pathology reports postoperatively were reviewed to determine the depth of invasion from the tumor specimen.

Results

72 tumour samples were available for analysis and 53 patients were included. For all tumors, both clinical depth (r = 0.779; p < 0.001) and radiographic depth (r =0.907; p <0.001) correlated well with pathological depth, with radiographic depth correlating slightly better. Clinical depth also correlated well with radiographic depth (r = 0.731; p < 0.001). By contrast, for superficial tumors (less than 5 mm on pathological measurement) neither clinical (r = 0.333, p = 0.34) nor radiographic examination (r = − 0.211; p = 0.56) correlated with pathological depth of invasion.

Conclusion

This is the first study evaluating the clinical assessment of tumor thickness in comparison to radiographic interpretation in oral cavity cancer. There are strong correlations between pathological, radiological, and clinical measurements in deep tumors (≥5 mm). In superficial tumors (<5 mm), clinical and radiological examination had low correlation with pathological thickness.

Clinical application of computed tomography-guided (125)I seed interstitial implantation for head and neck cancer patients with unmanageable cervical lymph node metastases

Background

To assess clinical application of computed tomography (CT)-guided ¹²⁵I seed implantation for patients who cannot endure or unwillingly receive repeated surgery, chemotherapy, or radiotherapy for unmanageable cervical lymph node metastases in head and neck cancer (HNC).

Methods

Thirty-one consecutive patients received CT-guided ¹²⁵I seed implantation between February 2010 and December 2013. To evaluate the clinical efficiency, karnofsky performance score (KPS), numeric rating scale (NRS), and tumor volume at 3-, and 6-month post-implantation were compared with pre-implantation, along with local control rate (LCR), overall survival rate (OSR), and complications at 3, 6 months, 1, and 2 years.

Results

The tumor volume was obviously decreased at 3-, and 6-month post-implantation (21.23 ± 8.83 versus 9.19 ± 7.52 cm²; 21.23 ± 8.83 versus 6.42 ± 9.79 cm²; P < 0.05) compared with pre-implantation. The NRS was statistically reduced (3.06 ± 1.06 versus 7.77 ± 0.92; 2.39 ± 1.15 versus 7.77 ± 0.92; P < 0.05), while KPS was significantly improved (83.18 ± 5.97 versus 73.60 ± 7.90; 82.86 ± 5.43 versus 73.60 ± 7.90; P < 0.05) postoperatively at 3 and 6 months, respectively. The LCR at 3, 6 months, 1, and 2 years was 96.30, 83.87, 64.51, and 45.16 %, respectively. The OSR was 100, 100, 67.74, and 45.16 %, respectively. Three cases experienced grade I and two had grade II acute radiation toxicity.

Conclusions

CT-guided seed implantation may be feasible and safe for HNC patients whose neck nodes are not manageable by routine strategies with fewer complications, higher LCR, and significant pain relief.

Diagnostic and Prognostic Value of Circulating Tumor Cells in Head and Neck Squamous Cell Carcinoma: a systematic review and meta-analysis

Several techniques have been developed to detect circulating tumor cells (CTC) in patients with head and neck squamous cell carcinoma (HNSCC), but their diagnostic and prognostic value are not yet fully established. A computerized retrieval of literatures was conducted without time restrictions using the electronic database in December 2014. Diagnostic accuracy variables were pooled and analyzed by the Meta-DiSc software. Engauge Digitizer and Stata software were used for pooled survival analysis. Twenty-two retrieved studies were eligible for systematic review, of which 9 conformed for the diagnostic test meta-analysis and 5 for the prognostic analysis. Subgroup analysis showed 24.6% pooled sensitivity and 100% pooled specificity of detections by using positive selection strategy, which moreover presented low heterogeneity. The presence of CTC was significantly associated with shorter disease free survival (DFS, HR 4.62, 95% CI 2.51-8.52). In conclusion, current evidence identifies the CTC detection assay as an extremely specific, but low sensitive test in HNSCC. Also, the presence of CTC indicates a worse DFS.

Sentinel lymph node biopsy in T1/T2 squamous cell carcinomas of the tongue: A prospective study

Commonly used staging procedures often cannot predict the absence of cervical metastases (CM) in squamous cell carcinomas (SCCs) of the oral cavity. Due to the high incidence of occult CM in numerous N0 cases in the clinic, an elective neck dissection (ND) is performed. The sentinel lymph node biopsy (SNB) is a common concept in the modern surgical therapy of malignancies. The present study evaluates the applicability of this concept for T1/T2-SCC of the tongue. In a prospective clinical study, 10 consecutive patients with T1/T2-SCC of the tongue and cN0 necks, were enrolled. Following sentinel lymph node (SLN) scintigraphy, all patients underwent SNB with a γ-probe and a subsequent ND. SNB specimens were compared with histopathological assessments of surgical specimens from the ND. A total of 5 female and 5 male patients (mean age, 52 years; women, 62 years; men, 42 years), with a median follow-up time of 33.5 months (range, 10–40 months), were treated. All patients presented with detectable SLNs. In 7 cases, the SLN(s) and the residual ND were negative for CM. In 3 cases, the SLN(s) were positive without further CM in the other neck nodes. Furthermore, 1 patient showed additional CMs after 10 months in the contralateral neck and lung metastasis after 18 months, but none at the time of the initial treatment. The concept of an SNB appears to be applicable to the management of the cN0 neck in small SCC of the tongue. The role of SNB in the management of SCC requires further investigation by prospective trials with larger patient numbers.

Superior cervical ganglion mimicking retropharyngeal adenopathy in head and neck cancer patients: MRI features with anatomic, histologic, and surgical correlation

INTRODUCTION

To describe the unique MRI findings of superior cervical ganglia (SCG) that may help differentiate them from retropharyngeal lymph nodes (RPLNs).

METHODS

A retrospective review of post-treatment NPC patients from 1999 to 2012 identified three patients previously irradiated for NPC that were suspected of having recurrent nodal disease in retropharyngeal lymph nodes during surveillance MRI. Subsequent surgical exploration revealed enlarged SCG only; no retropharyngeal nodal disease was found. A cadaveric head specimen was also imaged with a 3T MRI before and after dissection. In addition, SCG were also harvested from three cadaveric specimens and subjected to histologic analysis.

RESULTS

The SCG were found at the level of the C2 vertebral body, medial to the ICA. They were ovoid on axial images and fusiform and elongated with tapered margins in the coronal plane. T2-weighted (T2W) signal was hyperintense. No central elevated T1-weighted (T1W) signal was seen within the ganglia in non-fat-saturated sequences to suggest the presence of a fatty hilum. Enhancement after gadolinium was present. A central "black dot" was seen on axial T2W and post-contrast images in two of the three SCG demonstrated. Histology showed the central black line was comprised of venules and interlacing neurites within the central portion of the ganglion.

CONCLUSIONS

The SCG can be mistaken for enlarged RPLNs in post-treatment NPC patients. However, there are features which can help differentiate them from RPLNs, preventing unnecessary therapy. These imaging findings have not been previously described.

Micrometastatic cancer cells in lymph nodes, bone marrow, and blood: Clinical significance and biologic implications

Cancer metastasis may be regarded as a progressive process from its inception in the primary tumor microenvironment to distant sites by way of the lymphovascular system. Although this type of tumor dissemination often occurs in an orderly fashion via the sentinel lymph node (SLN), acting as a possible gateway to the regional lymph nodes, bone marrow, and peripheral blood and ultimately to distant metastatic sites, this is not a general rule as tumor cells may enter the blood and spread to distant sites, bypassing the SLN. Methods of detecting micrometastatic cancer cells in the SLN, bone marrow, and peripheral blood of patients have been established. Patients with cancer cells in their SLN, bone marrow, or peripheral blood have worse clinical outcomes than patients with no evidence of spread to these compartments. The presence of these cells also has important biologic implications for disease progression and the clinician's understanding of the process of cancer metastasis. Further characterization of these micrometastatic cancer cells at each stage and site of metastasis is needed to design novel selective therapies for a more "personalized" treatment.

The fatty acid synthase inhibitor orlistat reduces the growth and metastasis of orthotopic tongue oral squamous cell carcinomas

Fatty acid synthase (FASN) is the biosynthetic enzyme responsible for the endogenous synthesis of fatty acids. It is downregulated in most normal cells, except in lipogenic tissues such as liver, lactating breast, fetal lung, and adipose tissue. Conversely, several human cancers, including head and neck squamous cell carcinomas (HNSCC), overexpress FASN, which has been associated with poor prognosis and recently suggested as a metabolic oncoprotein. Orlistat is an irreversible inhibitor of FASN activity with cytotoxic properties on several cancer cell lines that inhibits tumor progression and metastasis in prostate cancer xenografts and experimental melanomas, respectively. To explore whether the inhibition of FASN could impact oral tongue squamous cell carcinoma (OTSCC) metastatic spread, an orthotopic model was developed by the implantation of SCC-9 ZsGreen LN-1 cells into the tongue of BALB/c nude mice. These cells were isolated through in vivo selection, show a more invasive behavior in vitro than the parental cells, and generate orthotopic tumors that spontaneously metastasize to cervical lymph nodes in 10 to 15 days only. SCC-9 ZsGreen LN-1 cells also exhibit enhanced production of MMP-2, ERBB2, and CDH2. The treatment with orlistat reduced proliferation and migration, promoted apoptosis, and stimulated the secretion of VEGFA165b by SCC-9 ZsGreen LN-1 cells. In vivo, the drug was able to decrease both the volume and proliferation indexes of the tongue orthotopic tumors and, importantly, reduced the number of metastatic cervical lymph nodes by 43%. These results suggest that FASN is a potential molecular target for the chemotherapy of patients with OTSCC.

Added value of the hybrid tracer indocyanine green-99mTc-nanocolloid for sentinel node biopsy in a series of patients with different lymphatic drainage patterns

INTRODUCTION

Indocyanine green (ICG)-(99m)Tc-nanocolloid is a novel hybrid fluorescent radioactive tracer for sentinel node (SN) biopsy. This study has aimed to evaluate the added value of this novel versatile tracer in a series of patients with different malignancies.

MATERIAL AND METHODS

Twenty patients (with penile carcinoma, oral cavity tumors, melanoma) were consecutively included between March-May 2012. Planar lymphoscintigraphy was performed 15 min and 2h after injection of ICG-(99m)Tc-nanocolloid followed by SPECT/CT. Blue dye (1 ml) was injected in 14 patients in surgery room. Intraoperatively, SNs were localized using a gamma probe and visualized by optical SN-detection using blue dye and fluorescence imaging. Finally, a portable gamma camera was used to confirm complete SN removal.

RESULTS

At least one SN was identified by SPECT/CT in all patients. All SNs (total 68, 100%) were excised using a combination of radio- and fluorescence guidance: 89.7% were intraoperatively localized with the gamma probe. The remaining SNs, located near the injection site, were localized using fluorescence imaging. During the surgery, 97% of the SNs were fluorescent while only 39.2% were stained blue. Ex vivo, all SNs were both radioactive and fluorescent. The SN was positive in 5 patients.

CONCLUSION

Synchronous radio- and fluorescence guided SN biopsy is feasible using ICG-(99m)Tc-nanocolloid. This hybrid approach combines the beneficial properties of both modalities. Adding fluorescence imaging improves optical SN detection compared to blue dye. It has been shown to be especially useful in the localization of SNs near the injection site.

DSG3 as a biomarker for the ultrasensitive detection of occult lymph node metastasis in oral cancer using nanostructured immunoarrays

OBJECTIVES

The diagnosis of cervical lymph node metastasis in head and neck squamous cell carcinoma (HNSCC) patients constitutes an essential requirement for clinical staging and treatment selection. However, clinical assessment by physical examination and different imaging modalities, as well as by histological examination of routine lymph node cryosections can miss micrometastases, while false positives may lead to unnecessary elective lymph node neck resections. Here, we explored the feasibility of developing a sensitive assay system for desmoglein 3 (DSG3) as a predictive biomarker for lymph node metastasis in HNSCC.

MATERIALS AND METHODS

DSG3 expression was determined in multiple general cancer- and HNSCC-tissue microarrays (TMAs), in negative and positive HNSCC metastatic cervical lymph nodes, and in a variety of HNSCC and control cell lines. A nanostructured immunoarray system was developed for the ultrasensitive detection of DSG3 in lymph node tissue lysates.

RESULTS

We demonstrate that DSG3 is highly expressed in all HNSCC lesions and their metastatic cervical lymph nodes, but absent in non-invaded lymph nodes. We show that DSG3 can be rapidly detected with high sensitivity using a simple microfluidic immunoarray platform, even in human tissue sections including very few HNSCC invading cells, hence distinguishing between positive and negative lymph nodes.

CONCLUSION

We provide a proof of principle supporting that ultrasensitive nanostructured assay systems for DSG3 can be exploited to detect micrometastatic HNSCC lesions in lymph nodes, which can improve the diagnosis and guide in the selection of appropriate therapeutic intervention modalities for HNSCC patients.

Near-infrared fluorescence sentinel lymph node mapping of the oral cavity in head and neck cancer patients

OBJECTIVES

Elective neck dissection is frequently performed during surgery in head and neck cancer patients. The sentinel lymph node (SLN) procedure can prevent the morbidity of a neck dissection and improve lymph node staging by fine pathology. Near-infrared (NIR) fluorescence imaging is a promising technique to identify the sentinel lymph node (SLN) intraoperatively. This feasibility study explored the use of indocyanine green adsorbed to human serum albumin (ICG:HSA) for SLN mapping in head and neck cancer patients.

MATERIALS AND METHODS

A total of 10 consecutive patients with oral cavity or oropharyngeal cancer and a clinical N0 neck were included. After exposure of the neck, 1.6 mL of ICG:HSA (500 μM) was injected at four quadrants around the tumor. During the neck dissection, levels I-IV were measured for fluorescence using the Mini-FLARE imaging system.

RESULTS

In all 10 patients, NIR fluorescence imaging enabled visualization of one or more SLNs. A total of 17 SLNs were identified. The mean contrast between the fluorescent signal of the lymph nodes and of the surrounding tissue was 8.7±6.4. In 3 patients, of which 1 was false-negative, lymph node metastases were found. After administration of ICG:HSA, the average number of fluorescent lymph nodes significantly increased over time (P<0.001).

CONCLUSION

This study demonstrated feasibility to detect draining lymph nodes in head and neck cancer patients using NIR fluorescence imaging. However, the fluorescent tracer quickly migrated beyond the SLN to higher tier nodes.

Concomitant radio- and fluorescence-guided sentinel lymph node biopsy in squamous cell carcinoma of the oral cavity using ICG-(99m)Tc-nanocolloid

PURPOSE

For oral cavity malignancies, sentinel lymph node (SLN) mapping is performed by injecting a radiocolloid around the primary tumour followed by lymphoscintigraphy. Surgically, SLNs can then be localized using a handheld gamma ray detection probe. The aim of this study was to evaluate the added value of intraoperative fluorescence imaging to the conventional radioguided procedure. For this we used indocyanine green (ICG)-(99m)Tc-nanocolloid, a hybrid tracer that is both radioactive and fluorescent.

METHODS

Fourteen patients with oral cavity squamous cell carcinoma were peritumourally injected with ICG-(99m)Tc-nanocolloid. SLNs were preoperatively identified with lymphoscintigraphy followed by single photon emission computed tomography (SPECT)/CT for anatomical localization. During surgery, SLNs were detected with a handheld gamma ray detection probe and a handheld near-infrared fluorescence camera. Pre-incision and post-excision imaging with a portable gamma camera was performed to confirm complete removal of all SLNs.

RESULTS

SLNs were preoperatively identified using the radioactive signature of ICG-(99m)Tc-nanocolloid. Intraoperatively, 43 SLNs could be localized and excised with combined radio- and fluorescence guidance. Additionally, in four patients, an SLN located close to the primary injection site (in three patients this SLN was located in level I) could only be intraoperatively localized using fluorescence imaging. Pathological analysis of the SLNs revealed a metastasis in one patient.

CONCLUSION

Combined preoperative SLN identification and intraoperative radio- and fluorescence guidance during SLN biopsies for oral cavity cancer proved feasible using ICG-(99m)Tc-nanocolloid. The addition of fluorescence imaging was shown to be of particular value when SLNs were located in close proximity to the primary tumour.

Decreased lymphangiogenesis and lymph node metastasis by mTOR inhibition in head and neck cancer

Despite our improved understanding of cancer, the 5-year survival rate for head and neck squamous cell carcinomas (HNSCC) patients remains relatively unchanged at 50% for the past three decades. HNSCCs often metastasize to locoregional lymph nodes, and lymph node involvement represents one of the most important prognostic factors of poor clinical outcome. Among the multiple dysregulated molecular mechanism in HNSCCs, emerging basic, preclinical, and clinical findings support the importance of the mTOR signaling route in HNSCC progression. Indeed, we observed here that the activation of mTOR is a widespread event in clinical specimens of HNSCCs invading locoregional lymph nodes. We developed an orthotopic model of HNSCC consisting of the implantation of HNSCC cells into the tongues of immunocompromised mice. These orthotopic tumors spontaneously metastasize to the cervical lymph nodes, where the presence of HNSCC cells can be revealed by histologic and immunohistochemical evaluation. Both primary and metastatic experimental HNSCC lesions exhibited elevated mTOR activity. The ability to monitor and quantitate lymph node invasion in this model system enabled us to explore whether the blockade of mTOR could impact HNSCC metastasis. We found that inhibition of mTOR with rapamycin and the rapalog RAD001 diminished lymphangiogenesis in the primary tumors and prevented the dissemination of HNSCC cancer cells to the cervical lymph nodes, thereby prolonging animal survival. These findings may provide a rationale for the future clinical evaluation of mTOR inhibitors, including rapamycin and its analogues, as part of a molecular-targeted metastasis preventive strategy for the treatment of patients with HNSCC.

Sentinel node biopsy for oral and oropharyngeal squamous cell carcinoma in the previously treated neck

In patients with early stage oral or oropharyngeal squamous cell carcinoma (OSCC) sentinel node biopsy (SNB) is a reliable method to detect occult disease in the neck. However, patients with a history of surgery or radiotherapy in the neck may have aberrant lymphatic drainage caused by disruption of lymphatic channels. Therefore, treatment of the same levels at risk as in the primary setting may not be appropriate. The aim of our prospective observational study was to evaluate the clinical application of SNB in previously treated OSCC. Between 2003 and 2010 twenty-two patients were included. Lymph node mapping consisted of preoperative lymphoscintigraphy, SPECT/CT, intraoperative use of gamma-probe and patent blue. Endpoints were the sentinel node (SN) detection rate, unexpected lymphatic drainage patterns, negative predictive value and regional tumor control. 4/22 (18%) Patients were previously treated only on the contralateral site. The SN detection rate was 100% and unexpected drainage was found in 1/4 patients. The other 18 patients had ipsi- or bilateral previous neck treatment and a SN detection rate of 83%. The upstaging rate was 7% and 67% had unexpected lymphatic drainage patterns. The median follow-up was 22 months. Regional tumor control and negative predictive value were 100%. SNB in previously treated OSCC patients is feasible. SN detection is reliable and regional tumor control after staging by SNB is excellent. Moreover, SNB renders an assessment of the individual lymphatic drainage pattern, compensating for a potential variability after previous treatment of the neck.

Long-term experience in sentinel node biopsy for early oral and oropharyngeal squamous cell carcinoma

OBJECTIVE

Long-term results of sentinel node biopsy (SNB) in early (T1/T2) oral and oropharyngeal squamous cell carcinoma (OSCC) in a single-institution experience.

METHODS

Prospective consecutive cohort analysis of 79 patients (67% male, median age 60 years, age range 34-87 years) included between 2000 and 2006. Lymphatic mapping consisted of preoperative lymphoscintigraphy, single photon emission computed tomography (SPECT/CT), and intraoperative use of a handheld gamma probe. Endpoints of the study were neck control rate, overall (OS), disease-specific (DSS), and disease-free survival (DFS).

RESULTS

Twenty-nine of 79 patients (37%) had positive sentinel nodes (SN). Six of 29 (21%) patients showed isolated tumor cells, 14/29 (48%) micrometastases, and 9/29 (31%) macrometastases. OS, DFS, and DSS at 5 years for the entire cohort were 80, 85, and 87%, for SN-negative patients were 88, 96, and 96%, and for SN-positive patients were 74, 73, and 77%, respectively. Only the difference in DSS achieved statistical significance. The neck control rate after 5 years was 96% in SN-negative and 74% in SN-positive patients. This difference was statistically significant.

CONCLUSIONS

SNB is a safe and accurate staging modality to select patients with clinically stage I/II OSCC with occult lymph node disease for elective neck dissection (END). The promising reported short-term results have been sustained by long-term follow-up. Patients with negative SN and no END achieve an excellent neck control rate which compares favorably with reports on primary END. The neck control rate in SN-negative patients is superior to that in SN-positive patients, which is reflected in superior DSS.

Sentinel node biopsy for oral and laryngopharyngeal squamous cell carcinoma: a retrospective study of 177 patients in Japan

OBJECTIVE

Sentinel node (SN) biopsy in the head and neck region has not been widely used in Japan, except at a few facilities. However, almost all these facilities perform preoperative localization and intraoperative diagnosis by frozen section analysis of SN to select patients who must undergo neck dissection in a one-stage procedure. The objective of this study was to determine the actual status of SN biopsy at those facilities in Japan that have actively conducted this procedure, and to elucidate the usefulness and drawbacks of this technique in head and neck cancer.

METHODS

We retrospectively reviewed 177 patients who had undergone SN biopsy at 7 facilities. The underlying pathology was laryngeal or hypopharyngeal cancer in 20 patients from one hospital, while the remaining 157 patients had oral cancer. Preoperative localization of SN was determined using conventional lymphoscintigraphy with or without single photon emission computed tomography with CT (SPECT-CT). Intraoperative localization and diagnosis of SN were performed by gamma probe and frozen section analysis.

RESULTS

Conventional lymphoscintigraphy detected a mean of 2.6 SNs per patient in 137 patients with oral cancer, compared to 2.7 in 71 patients using SPECT-CT and 2.9 in 154 patients using the gamma probe. No significant differences were apparent between techniques. Forty of the 520 SNs (7.7%; 33 in oral cancer and 7 in laryngeal or hypopharyngeal cancer) were pathologically positive in the final diagnosis. Of these, 3 were not processed for frozen sectioning and were diagnosed only with hematoxylin and eosin staining. Among the others, 32 (86.5%) were diagnosed intraoperatively as showing metastasis. In terms of the false-negative rate, 144 patients were determined by SN biopsy to have no positive SNs. Of these, 2 patients had non-SN metastases found in their dissected neck and 8 patients without neck dissection showed late nodal recurrence. The false-negative rate was thus 6.9%.

CONCLUSION

Frozen section analysis, particularly multislice sectioning, offers a relatively reliable intraoperative diagnostic method. We were able to perform immediate neck dissection based on the results of multislice sectioning as a single-stage procedure.

Oral cavity squamous cell carcinoma and the clinically n0 neck: the past, present, and future of sentinel lymph node biopsy

Oral cavity squamous cell carcinoma (OCSCC) has a yearly incidence of 274,000 patients. Twenty percent to 30% of patients will harbor occult regional metastases, an important feature that correlates with worse outcomes. Supraomohyoid neck dissection (SND) is the gold standard treatment, but because of recent successes of sentinel lymph node (SLN) biopsy in the management of breast cancer and melanoma, many have begun evaluating its use in head and neck mucosal cancers. SLN biopsy offers patients decreased morbidity compared with SND, and has shown reproducibly low false-negative rates, high-negative predictive values, and high sensitivities. Limitations with floor-of-mouth primaries and delayed secondary SNDs have been described, but a new agent designed to address these shortcomings, Lymphoseek (Neoprobe Corp.; Dublin, OH), is currently under investigation. This article reviews the current literature on SLN biopsy and introduces a phase 3 study evaluating the efficacy of Lymphoseek in SLN biopsy of OCSCCs.